Therapeutic Approaches

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Therapeutic Approaches
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• Therapeutic Groups
• Intervention with Families
• Mileu Therapy
• Relaxation Therapy
• Assertiveness Therapy
• Promoting Self-Esteem
• Behavioral Therapy
• Cognitive Therapy

• Electroconvulsive Therapy
• Complementary Therapy
• Client Education

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Functions of a Group

• Socialization.
• Support.
• Task completion.
• Camaraderie.
• Informational.
• Normative.
• Empowerment.
• Governance.

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Types of Groups

• Task groups. This is a group formed to accomplish
  a specific outcome.
• Teaching groups. The focus is to convey knowledge
  and information to a number of individuals.
• Supportive/therapeutic groups. The primary
  concern is to prevent possible future upsets by
  teaching the participants effective ways of
  dealing with emotional stress arising from
  situational or developmental crises.
• Therapeutic groups vs. group therapy
• Group therapy has a sound theoretical base, and
  leaders generally have advanced degrees in
  psychology, social work, nursing, or medicine.
• Therapeutic groups are based to a lesser extent
  on theory. Focus is on group relations,
  interactions between group members, and the
  consideration of a selected issue.
• Leaders of both types of groups must be
  knowledgeable about group process (the way in
  which group members interact with each other) as
  well as group content (the topic or issue being
  discussed in the group).

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• Self-help groups
• Composed of individuals with a similar problem
  
• Serve to reduce the possibilities of further
  emotional distress leading to pathology and
  necessary treatment
• May or may not have a professional leader. Run
  by members, and leadership often rotates from
  member to member

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The Role of the Nurse in Group Therapy

• Nurses who work in psychiatry may lead various
  types of therapeutic groups, such as client
  education groups, assertiveness training, support
  groups for clients with similar problems, parent
  groups, transition to discharge groups, and
  others.
• Guidelines set forth by the American Nurses
  Association specify that nurses who serve as
  group psychotherapists should have a minimum of a
  masters degree in psychiatric nursing.

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Curative Factors of Groups

• Instillation of hope.
• Universality.
• Imparting of information.
• Altruism.
• Corrective recapitulation of the primary family
  group.
• Development of socializing techniques.
• Imitative behavior.
• Interpersonal learning.
• Group cohesiveness.
• Catharsis.
• Existential factors.

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Phases of Group Development

• Initial or Orientation Phase
• Leader and members work together to establish
  rules and goals for the group.
• Leader promotes trust and ensures that rules do
  not interfere with fulfillment of the goals.
• Members are superficial and overly polite. Trust
  has not yet been established.
• Middle or Working Phase
• Productive work toward completion of the task is
  undertaken.
• Leader role diminishes
• and becomes more one
• of facilitator.
• Trust has been established between the members,
  and cohesiveness exists.
• Conflict is managed by the group members
  themselves.
• Final or Termination Phase
• A sense of loss, precipitating
• the grief process, may be
• experienced by group members.
• The leader encourages the group members to
  discuss these feelings of loss and to reminisce
  about the accomplishments of the group.
• Feelings of abandonment may be experienced by
  some members. Grief for previous losses may be
  triggered.

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Leadership Styles

• Autocratic.
• Democratic.
• Laissez-faire.

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Member Roles

• Members play one of three types of roles within a
  group
• Task roles serving to complete the task of the
  
• group
• Maintenance roles maintaining or enhancing
  group processes
• Individual (personal) roles
• fulfilling personal or individual
• needs
• Members play one of three types of roles within a
  group
• Task roles serving to complete the task of the
  
• group
• Maintenance roles maintaining or enhancing
  group processes
• Individual (personal) roles
• fulfilling personal or individual
• needs

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Family Therapy
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Family Therapy

• The family defined
• A family is who they say they are. (Wright
  Leahy, 2000)
• Types of Families
• Biological family of procreation
• Nuclear family (incorporates one or more members
  of the extended family)
• Sole-parent family
• Stepfamily
• Communal family
• Homosexual couple or family

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Family Functioning

• Boyer and Jeffrey describe six elements on which
  families are assessed to be either functional or
  dysfunctional.
• 1. Communication
• 2. Self-concept Reinforcement
• 3. Family Members Expectations
• 4. Handling Differences
• 5. Family Interactional Patterns
• 6. Family Climate

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• Nursing Assessment
• Nursing Diagnosis
• Nursing Interventions
• Goals

Milieu Therapy The Therapeutic Community
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Milieu Therapy The Therapeutic Community

• The psychiatric-mental health nurse provides
  structures, and maintains a therapeutic
  environment in collaboration with the client and
  other health care clinicians.
• Milieu therapy, or therapeutic community, is
  defined as a scientific structuring of the
  environment to effect behavioral changes and to
  improve the psychological health and functioning
  of the individual.

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Basic Assumptions

• The health of each individual is to be realized
  and encouraged to grow.
• Every interaction is an opportunity for
  therapeutic intervention.
• The client owns his or her own environment.
• Each client owns his or her own behavior.
• Peer pressure is a useful and powerful tool.
• Inappropriate behaviors are dealt with as they
  occur.
• Restrictions and punishment are to be avoided.

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Basic Assumptions

• A treatment plan is directed by an
  interdisciplinary team.
• The plan is formulated by the team.
• Team members of all disciplines sign the plan and
  meet weekly to update the plan as needed.
• Disciplines may include psychiatry, psychology,
  nursing, social work, occupational therapy,
  recreational therapy, art therapy, music therapy,
  dietetics, and chaplains service.

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Role of the Nurse

• Through use of the nursing process, nurses manage
  the therapeutic environment on a 24-hour basis.
• Nurses have the responsibility for ensuring that
  the clients physiological and psychological
  needs are met.
• Nurses are also responsible for
• Medication administration
• Development of a one-to-one relationship
• Setting limits on unacceptable behavior
• Client education

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Crisis Intervention

• Any stressful situation can precipitate a crisis.
• Assistance with problem-solving during
• the crisis period preserves self-esteem and
  promotes growth with resolution.
• Crisis is defined as a sudden event in ones life
  that disturbs homeostasis, during which usual
  coping mechanisms cannot resolve the problem.

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• Characteristics of a Crisis
• Crisis occurs in all individuals at one time or
  another and is
• not necessarily equated with
  psychopathology.
• Crises are precipitated by specific identifiable
  events.
• Crises are personal by nature.
• Crises are acute, not chronic, and are resolved
  in one way or another within a brief period.
• A crisis situation contains the potential for
  psychological growth or deterioration.

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Phases in the Development of a Crisis

• 1. The individual is exposed to a precipitating
  stressor.
• 2. When previous problem-solving techniques do
  not relieve the
• stressor, anxiety increases further.
• 3. All possible resources, both internal and
  external, are called on
• to resolve the problem and relieve the
  discomfort.
• 4. If resolution has not occurred in previous
  phases, the tension
• mounts beyond a further threshold or its
  burden increases over
• time to a breaking point. Major
  disorganization of the
• individual with drastic results often occurs.
  
• Whether individuals experience a crisis in
  response to a stressful
• situation depends on three factors
• The individuals perception of the event
• The availability of situational supports
• The availability of adequate coping mechanisms

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Types of Crises

• Dispositional crises
• Crises of anticipated life transitions
• Crises resulting from traumatic stress
• Crises resulting from traumatic stress
• Psychiatric emergencies

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Crisis Intervention

• Nurses may be called on to function as crisis
  helpers in virtually any setting committed to
  practice of nursing.
• Phase 1. Assessment.
• Phase 2. Planning of therapeutic intervention
• Phase 3. Intervention
• Assessment
• Evaluation

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Relaxation Therapy

• Deep breathing exercises
• Progressive relaxation
• Modified (or passive) progressive relaxation
• Meditation
• Mental imagery
• Biofeedback
• Physical exercise

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• Nursing intervention
• Patient Education

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Assertiveness Training

• Honesty is basic to assertive behavior and is
  expressed in a manner that promotes self-respect
  and respect for others.
• Basic Human Rights

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Four Common Response Patterns

• Nonassertive behavior
• Assertive behavior
• Aggressive behavior.
• Passive-aggressive behavior.

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Techniques that Promote Assertive Behavior

• Standing up for ones basic human rights
• Assuming responsibility for own statements
• Responding as a broken record persistently
  repeating in a calm voice what is wanted
• Agreeing assertively assertively accepting
  negative aspects about oneself admitting where
  an error has been made
• Inquiring assertively seeking additional
  information about critical statements

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• Shifting from content to process changing the
  focus of the communication from discussing the
  topic at hand to analyzing what is actually going
  on in the interaction
• Clouding/fogging concurring with the critics
  argument without becoming defensive and without
  agreeing to change
• Defusing putting off further discussion with an
  angry individual until he or she is calmer
• Delaying assertively putting off further
  discussion with another individual until he or
  she is calmer
• Responding assertively with irony

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Nurses Role

• Education-
• Thought-Stopping Techniques

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Promoting Self-Esteem

• Healthy self-esteem has been described as
  essential for psychological survival.
• An awareness of self is an important
  differentiating factor between humans and other
  animals.
• Self-concept has been defined as the cognitive
  or thinking component of the self, and generally
  refers to the totality of a complex, organized,
  and dynamic system of learned beliefs, attitudes,
  and opinions that each person holds to be true
  about his or her personal existence.
  Self-concept consists of the following three
  components The physical self, or body image,
  personal identity and Self-esteem

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Boundaries

• Types of physical boundaries include physical
  closeness, touching, sexual behavior, eye
  contact, privacy, and pollution.
• Touching someone who does not want to be touched
  is an example of an invasion of a physical
  boundary.
• Types of psychological boundaries include
  beliefs, feelings, choices, needs, time alone,
  interests, confidences, individual differences,
  and spirituality.
• Being criticized for doing something differently
  from others is an example of an invasion of a
  psychological boundary.

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• Boundary pliancy Boundaries can be rigid,
  flexible, or enmeshed
• Rigid boundaries occur when people have a very
  narrow
• perspective on life. They perceive that
  things must be one way
• and refuse to change for any reason.
• Flexible boundaries occur when people are able
  to let go of their boundaries as appropriate.
  Healthy boundaries are flexible.
• Enmeshed boundaries occur when two peoples
  boundaries are so blended together that neither
  can be sure where one stops and the other begins.
  An individual with an enmeshed boundary is unable
  to differentiate his or her wants and needs from
  those of the other person.

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The Nursing Process
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Behavior Therapy

• A behavior is considered to be maladaptive when
  it Is age-inappropriate
• Interferes with adaptive functioning
• Is misunderstood by others in terms of cultural
  inappropriateness
• The behavioral approach to therapy is that people
  have become what they are through learning
  processes or through the interaction of the
  environment with their genetic endowment.
• The basic assumption is that problematic
  behaviors occur when there has been inadequate
  learning and therefore can be corrected through
  the provision
• of appropriate learning experiences.

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• Classical Conditioning
• Operant Conditioning

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Techniques for Modifying Client Behavior

• Shaping.
• Modeling.
• Premack principle.
• Extinction.
• Contingency contracting.
• Token economy.
• Time out.
• Reciprocal inhibition.
• Overt sensitization.

• Covert sensitization.
• Systematic desensitization.
• Flooding.

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Role of the Nurse
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Cognitive Therapy

• The foundation on which cognitive therapy is
  established can be identified by the statement,
  Men are disturbed not by things but by the views
  which they take of them.

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Indications for Cognitive Therapy

• Depression
• Panic disorder
• Generalized anxiety disorder
• Social phobia
• Obsessive-compulsive disorder
• Posttraumatic stress disorder

• Substance abuse
• Personality disorders
• Schizophrenia
• Couples problems
• Bipolar disorder
• Hypochondriasis
• Somatoform disorder
• Eating disorders

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• Automatic thoughts thoughts that occur rapidly
  in response to a situation and without rational
  analysis sometimes called cognitive errors

• Some examples are
• Arbitrary inference
• Overgeneralization
• Dichotomous thinking
• Selective abstraction
• Magnification
• Minimization
• Catastrophic thinking
• Personalization

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Basic Concepts

• The general thrust of cognitive therapy is that
  emotional responses are largely dependent on
  cognitive appraisals of the significance of
  environmental cues. (Wright, Beck, Thase,
  2003)

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Electroconvulsive Therapy

• ECT is the induction of a grand mal (generalized)
  
• seizure through the application of electrical
• current to the brain.
• Stimulus is applied through electrodes placed
  bilaterally in the frontotemporal region or
  unilaterally on the same side as the dominant
  hand.
• Dose of stimulation is based on the clients
  seizure threshold, which is highly variable among
  individuals.
• The duration of the seizure should be at least 25
  seconds.
• Usually administered every other day, for three
  times per week most clients need 6 to 12
  treatments.

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• Indications
• Contraindications
• Contraindications
• Risks Associated with ECT
• Role of the Nurse

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Complementary Therapies

• The connection between mind and body is well
  recognized.
• Traditional medicine practiced in the United
  States is
  based on scientific methodology and is known
  as allopathic medicine.
• Practices that differ from the usual traditional
  practices
• are known as alternative medicine.

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• The Office of Alternative Medicine was
  established by the National Institutes of Health
  in 1991 to study nontraditional therapies and to
  evaluate their usefulness and effectiveness. The
  name has been changed to the National Center for
  Complementary and Alternative Medicine.
• Increasing numbers of third-party payers are
  bowing to public pressure and including
  alternative therapies in their coverage.
• Some clinicians view these therapies not as
  alternatives but as complementary therapies in
  partnership with traditional medicine

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• Complementary medicine is viewed as holistic
  health care, which deals not only with the
  physical perspective but also with the emotional
  and spiritual components of the individual.
• Most complementary therapies are not founded on
  scientific principles, but they have been shown
  to be effective in the treatment of certain
  disorders and merit further examination as a
  viable component of holistic health care.

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Types of Complementary Therapies

• Herbal Medicine
• Acupressure and Acupuncture
• Diet and Nutrition
• Chiropractic Medicine
• Therapeutic Touch
• Massage
• Yoga
• Pet Therapy

• Aromatherapy
• Hypnosis
• Meditation
• Guided imaging
• others

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Client Education

• Client education has been defined as the process
  of influencing behavior, producing the changes in
  knowledge, attitudes, and skills necessary to
  maintain or improve health. It is a holistic
  process with the goal of changing a patients
  behavior to benefit his or her health status.
  (Rankin, Stallings, London, 2005)
• Standard Ve of the ANA Standards of
  Psychiatric-Mental Health Nursing Practice
  pertains to Health Teaching.
• Health teaching is required by the nurse practice
  acts and the Joint Commission on Accreditation of
  Healthcare Organizations (JCAHO).

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Nursing

• Assessment
• Nursing Diagnosis
• Outcome Identification
• Planning/Implementation
• Evaluation
• Documentation of Client Education